Background and purpose: Rapid thrombectomy for acute ischemic stroke caused by large vessel occlusion leads to improved outcome. Optimizing intrahospital management might diminish treatment delays. To examine if one-stop management reduces intrahospital treatment delays and improves functional outcome of acute stroke patients with large vessel occlusion. Methods: We performed a single center, observational study from June 2016 to November 2018. Imaging was acquired with the latest generation angiography suite at a comprehensive stroke center. Two-hundred-thirty consecutive adults with suspected acute stroke presenting within 6 h after symptom onset with a moderate to severe National Institutes of Health Stroke Scale (≥10 in 2016; ≥7 since January 2017) were directly transported to the angiography suite by bypassing multidetector CT. Noncontrast flat-detector CT and biphasic flat-detector CT angiography were acquired with an angiography system. In case of a large vessel occlusion patients remained in the angiography suite, received intravenous rtPA therapy and underwent thrombectomy. As primary endpoints, door-to-reperfusion times and functional outcome at 90 days were recorded and compared in a case-control analysis with matched prior patients receiving standard management. Results: A total of 230 patients (123 women, median age of 78 years (Interquartile Range (IQR) 69–84)) were included. Median symptom-to-door time was 130 min (IQR 70–195). Large vessel occlusion was diagnosed in 166/230 (72%) patients; 64/230 (28%) had conditions not suitable for thrombectomy. Median door-to-reperfusion time for M1 occlusions was 64 min (IQR 56–87). Compared to 43 case-matched patients triaged with multidetector CT, median door-to-reperfusion time was reduced from 102 (IQR 85–117) to 68 min (IQR 53–89; p < 0.001). Rate of good functional outcome was significantly better in the one-stop management group (p = 0.029). Safety parameters (mortality, sICH, any hemorrhage) did not differ significantly between groups. Conclusions: One-stop management for stroke triage reduces intrahospital time delays in our specific hospital setting.

Background and purposeFlat detector CT (FDCT) has been used as a peri-interventional diagnostic tool in numerous studies with mixed results regarding image quality and detection of intracranial lesions. We compared the diagnostic aspects of the latest generation FDCT with standard multidetector CT (MDCT).Materials and methods102 patients were included in our retrospective study. All patients had undergone interventional procedures. FDCT was acquired peri-interventionally and compared with postinterventional MDCT regarding depiction of ventricular/subarachnoidal spaces, detection of intracranial hemorrhage, and delineation of ischemic lesions using an ordinal scale. Ischemic lesions were quantified with the Alberta Stroke Program Early CT Scale (ASPECTS) on both examinations. Two neuroradiologists with varying grades of experience and a medical student scored the anonymized images separately, blinded to the clinical history.ResultsThe two methods were of equal diagnostic value regarding evaluation of the ventricular system and the subarachnoidal spaces. Subarachnoidal, intraventricular, and parenchymal hemorrhages were detected with a sensitivity of 95%, 97%, and 100% and specificity of 97%, 100%, and 99%, respectively, using FDCT. Gray–white differentiation was feasible in the majority of FDCT scans, and ischemic lesions were detected with a sensitivity of 71% on FDCT, compared with MDCT scans. The mean difference in ASPECTS values on FDCT and MDCT was 0.5 points (95% CI 0.12 to 0.88).ConclusionsThe latest generation of FDCT is a reliable and accurate tool for the detection of intracranial hemorrhage. Gray–white differentiation is feasible in the supratentorial region.

The combined first-pass deployment of a stent-retriever and an aspiration-catheter was the most effective technique for reperfusion of anterior circulation large vessel occlusion. Our results correlate with the latest single-centrere studies, reporting very high reperfusion rates with PCA variations.

Background Embolectomy is the standard of care in acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). Aim of this study was to compare two techniques: A Direct Aspiration First Pass Technique (ADAPT) and Stent-retriever Assisted Vacuum-locked Extraction (SAVE) stratified by the occluded vessel. Methods One hundred seventy-one patients (71 male) treated between January 2014 and September 2017 with AIS due to LVO of the anterior circulation (55 carotid T, 94 M1, 22 M2) were included. Treatment techniques were divided into two categories: ADAPT and SAVE. Primary endpoints were successful reperfusion (mTICI ≥2b), near-perfect reperfusion (mTICI ≥2c) and groin puncture to reperfusion time. Secondary endpoints were the number of device-passes, first-pass reperfusion, the frequency of emboli to new territory (ENT), clinical outcome at 90 days, and the frequency of symptomatic intracranial hemorrhage (sICH). Analysis was performed on an intention to treat basis. Results Overall, SAVE resulted in significant higher rates of successful reperfusion (mTICI≥2b) compared to ADAPT (93.5% vs 75.0%; p = 0.006). After stratification for the occluded vessel only the carotid T remained significant with higher rates of near-perfect reperfusion (mTICI≥2c) (55.2% vs 15.4%; p = 0.025), while for successful reperfusion a trend remained (93.1% vs 65.4%; p = 0.10). Groin to reperfusion times were not significantly different. Secondary analysis revealed higher rates of first-pass successful reperfusion (59.6% vs 33.3%; p = 0.019), higher rates of first-pass near-perfect reperfusion in the carotid T (35.4% vs 16.7%; p = 0.038) and a lower number of device-passes overall (median 1 IQR 1–2 vs 2 IQR 2–3; p <  0.001) and in the carotid T (median 2 IQR 1.3 vs 3 IQR 2–5; p <  0.001) for SAVE. Clinical outcome and safety parameters were comparable between groups. Conclusions Embolectomy using SAVE appears superior to ADAPT, especially for carotid T occlusions with regard to reperfusion success.

Mechanical thrombectomy using the SAVE technique seems to be effective, fast and safe. First-line use of SAVE leads to high rates of complete and near complete reperfusion.

BackgroundA thrombolysis in cerebral infarction (TICI) score of 2b is defined as a good recanalization result although the reperfusion may only cover 50% of the affected territory. An additional mTICI2c category was introduced to further differentiate between mTICI scores. Despite the new mTICI2c category, mTICI2b still covers a range of 50–90% reperfusion which might be too imprecise to predict neurological improvement after therapy.AimTo compare the 7-point “expanded TICI” (eTICI) scale with the traditional mTICI in regard to predict functional independence at 90 days.MethodsRetrospective review of 225 patients with large artery occlusion. Angiograms were graded by 2 readers according the 7-point eTICI score (0% = eTICI0; reduced clot = eTICI1; 1–49% = eTICI2a, 50–66% = eTICI2b50; 67–89% = eTICI2b67, 90–99% = eTICI2c and complete reperfusion = eTICI3) and the conventional mTICI score. The ability of e- and mTICI to predict favorable outcome at 90days was compared.ResultsGiven the ROC analysis eTICI was the better predictor of favorable outcome (p-value 0.047). Additionally, eTICI scores 2b50, 2b67 and 2c (former mTICI2b) were significantly superior at predicting the probability of a favorable outcome at 90 days after endovascular therapy with a p-value of 0.033 (probabilities of 17% for mTICI2b50, 24% for mTICI2b67 and 54% for mTICI2c vs. 36% for mTICI2b).ConclusionsThe 7-point eTICI allows for a more accurate outcome prediction compared to the mTICI score because it refines the broad range of former mTICI2b results.

BackgroundData on the frequency and outcome of repeated mechanical thrombectomy (MT) in patients with short-term re-occlusion of intracranial vessels is limited. Addressing this subject, we report our multicenter experience with a systematic review of the literature.MethodsA retrospective analysis was conducted of consecutive acute stroke patients treated with MT repeatedly within 30 days at 10 tertiary care centers between January 2007 and January 2020. Baseline demographics, etiology of stroke, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at 90 days were noted. Additionally, a systematic review of reports with repeated MT due to large vessel occlusion (LVO) recurrence was performed.ResultsWe identified 30 out of 7844 (0.4%) patients who received two thrombectomy procedures within 30 days due to recurrent LVO. Through systematic review, three publications of 28 participants met the criteria for inclusion. Combined, a total of 58 participants were analyzed: cardioembolic events were the most common etiology for the first (65.5%) and second LVO (60.3%), respectively. Median baseline NIHSS (National Institutes of Health Stroke Scale) was 13 (IQR 8–16) before the first MT and 15 (IQR 11–19) before the second MT (p=0.031). Successful reperfusion was achieved in 91.4% after the first MT and in 86.2% patients after the second MT (p=0.377). The rate of functional independence (mRS 0–2) was 46% at 90 days after the second procedure.ConclusionRepeated MT in short-term recurrent LVO is a rarity but appears to be safe and effective. The second thrombectomy should be pursued with the same extensive effort as the first procedure as these patients may achieve similar good outcomes.

Background: Endovascular treatment (EVT) for large vessel occlusion stroke (LVOS) is highly effective. To date, it remains controversial if intravenous thrombolysis (IVT) prior to EVT is superior compared with EVT alone. The aim of our study was to specifically address the question, whether bridging IVT directly prior to EVT has additional positive effects on reperfusion times, successful reperfusion, and functional outcomes compared with EVT alone.Methods: Patients with LVOS in the anterior circulation eligible for EVT with and without prior IVT and direct admission to endovascular centers (mothership) were included in this multicentric, retrospective study. Patient data was derived from the German Stroke Registry (an open, multicenter, and prospective observational study). Outcome parameters included groin-to-reperfusion time, successful reperfusion [defined as a Thrombolysis in Cerebral Infarction (TICI) scale 2b-3], change in National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and mortality at 90 days.Results: Of the 881 included mothership patients with anterior circulation LVOS, 486 (55.2%) received bridging therapy with i.v.-rtPA prior to EVT, and 395 (44.8%) received EVT alone. Adjusted, multivariate linear mixed effect models revealed no difference in groin-to-reperfusion time between the groups (48 ± 36 vs. 49 ± 34 min; p = 0.299). Rates of successful reperfusion (TICI ≥ 2b) were higher in patients with bridging IVT (fixed effects estimate 0.410, 95% CI, 0.070; 0.750, p = 0.018). There was a trend toward a higher improvement in the NIHSS during hospitalization [ΔNIHSS: bridging-IVT group 8 (IQR, 9.8) vs. 4 (IQR 11) points in the EVT alone group; fixed effects estimate 1.370, 95% CI, −0.490; 3.240, p = 0.149]. mRS at 90 days follow-up was lower in the bridging IVT group [3 (IQR, 4) vs. 4 (IQR, 4); fixed effects estimate −0.350, 95% CI, −0.680; −0.010, p = 0.041]. There was a non-significantly lower 90 day mortality in the bridging IVT group compared with the EVT alone group (22.4% vs. 33.6%; fixed effects estimate 0.980, 95% CI −0.610; 2.580, p = 0.351). Rates of any intracerebral hemorrhage did not differ between both groups (4.1% vs. 3.8%, p = 0.864).Conclusions: This study provides evidence that bridging IVT might improve rates of successful reperfusion and long-term functional outcome in mothership patients with anterior circulation LVOS eligible for EVT.